Application, Medical History/Release Form

2015 APPLICATION FOR MEMBERSHIP
The Oregon Crusaders thanks you for your interest in being a part of the Oregon Crusaders Drum and Bugle Corps.
The following information should be completed and turned in when you audition for the Oregon Crusaders. If you
have any questions, please email the Director at [email protected].
Member Information
Name:
Date of Birth:
Home Address:
City/State
Email Address :
Home Phone #:
School Name:
Cell #:
Instrument or Position:
Food preferences:
Zip:
YOU MUST PROVIDE PARENT CONTACT INFORMATION IN CASE OF AN EMERGENCY
PRIMARY Parent/Guardian Information #1
Name:
Home Phone #:
Address:
City/State:
Email Address :
Work #:
What is your occupation?
Business or Company name:
Zip:
Cell #:
Parent/Guardian Information #2
Name:
Home Phone #:
Address:
City/State:
Email Address :
Work #:
What is your occupation?
Business or Company name:
Have you ever been a member of any other drum and bugle corps?
Do you owe any other corps money, equipment or uniforms?
______________________________________
(Member Signature)
Zip:
Cell #:
If so, which corps?
If so, please explain?
_______________________
(Date)
I hereby give my permission for my child/ward to participate in the activities of the Oregon Crusaders Drum and Bugle Corps. I
do hereby indemnify and hold harmless the Administration, Officers, Directors, Staff, Volunteers, Chaperones, Boosters,
Sponsors and Affiliated Persons and Organizations from any accidents or injuries resulting from such participation.
______________________________________
(Primary Parent or Guardian Signature, if under 18)
_______________________
(Date)
Turn in all complete forms at a camp or send to Colleen Bledsoe at [email protected]
2015 MEDICAL INFORMATION FORM
Participant’s Name: _______________________________________
Date of Birth:______________________
(Please include middle initial)
Email Address:_______________________________________________ Cell Phone:______________________
Primary Parent/Guardian #1 Name: ________________________________________ Phone: ______________________
(Please include middle initial)
Address:______________________________________ City State:__________________________ Zip:_______
Email Address:____________________________ Work Phone:_______________ Cell Phone: ________________
Parent/Guardian #2 Name: _________________________________________ Phone:______________________
(Please include middle initial)
Address:______________________________________ City State:__________________________ Zip:_______
Email Address:____________________________ Work Phone:_______________ Cell Phone: ________________
Emergency Contact Information
(Other than the people listed above if possible)
Name:______________________________
Relation:____________________
Phone:_________________
Insurance/Physician Information
Person Carrying Insurance:________________________ Relation:____________
Doctor’s Name:________________________________________ Office Phone:_________________________
Insurance Provider:____________________ Group #:
ID #:
Special Instructions on Insurance:______________________________________________________________
** All medications must be registered on this form **
Do you have any medical issues that have or may prevent you from participating in rehearsals, performances, or tour activities that the
Oregon Crusaders should be aware of? ___Yes ___No If yes, please explain:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Are you required to take any prescribed medication on a regular basis? ___Yes ___No
If yes, please list prescriptions and regularity: ____________________________________________________________________
It is the member’s responsibility to provide their own prescription and non-prescription medications, wraps, braces, etc. that may be of normal
use for them. Some prescription medications should be given to a designated staff member for distribution as required such as narcotics,
ADHD medications that are known for their high levels of abuse or theft. Any rescue medications such as Epi Pens® and inhalers should be
on the participant at all times.
Please sign to grant permission to the Oregon Crusaders to give non-prescription medication to you in case of an emergency or injury:
__________________________________________________
Do you have any allergies (including FOOD, medications, etc)? ___Yes ___No If yes, please explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Turn in all complete forms at a camp or send to Colleen Bledsoe at [email protected]
Participation Consent and Release, Liability Waiver, and Indemnity Agreement
In consideration for participation of the undersigned participant in the Oregon Crusaders Drum and Bugle Corps program(s) (“Corps”),
we, the undersigned, with the intent to be legally bound, do for ourselves, our heirs, executors, administrators and all others claiming by, or
through us, do hereby state that we consent to the participant’s participation in the Corps’ activities. We are aware of all risks, hazards, and
uncertainties connected with participation in the programs and activities of the Corps.
We hereby waive, release, and discharge the Corps and all of its officers, directors, officials, instructors, employees, volunteers, and
any other individuals acting for or on behalf of the Corps, from any and all claims while participating in, traveling to or from, or competing in any
of the activities or functions of the Corps. It is our specific intent to release, acquit, and forever discharge the Corps, all of its officers, directors,
officials, instructors, employees, volunteers, and any other individuals acting for or on behalf of the corps from all claims, demands, actions,
causes of action and from all liability for injury, damage or loss of whatsoever kind, nature or description that may arise or be sustained by the
participant which is due or in any way connected with the participant’s participation in the Corps or any of its functions or activities. It is further
our specific intent that this release applies to any injury, damage, or claim arising from any act or omission of the Corps or any of the individuals
released hereby including any injury, damage, or claim arising from any negligent act or negligent omission of the Corps or individuals released
hereby.
The participant and the undersigned hereby assume full responsibility for all risk of bodily injury, death, or property damage due to
the negligence or other conduct of those parties released hereby or otherwise, as a result of any activities connected in any way with the
Corps. The undersigned and participant on behalf of themselves and all of their heirs, executors and administrators and all others do hereby
further agree not to sue the Corps or any of the individuals released hereby in the event of any injury or damage of any kind or description
whatsoever. This includes any claim, demand, or suit by the minor participant either before he or she reaches the age of majority or
thereafter.
The undersigned further agree to indemnify and hold the Corps, and all of those individuals released hereby, completely and
absolutely harmless from all expenses, demands, claims, fees and costs of whatsoever description or nature which may arise as the result of
any such claims being instituted any time. This includes all costs, fees, and expenses involved in defending or investigating any and all
claims, demands, or causes of action whatsoever that may hereafter be asserted or brought by the participant or anyone on his or her behalf
for the purpose of enforcing any claim for damages sustained during participation in any of the activities of the Corps.
Emergency Medical Authorization
I (We), the undersigned, do hereby consent and authorize any duly authorized doctor, emergency medical technician, hospital or other
medical facility to treat or attempt to treat the participant for any injuries received by said participant while he or she participates in any activity
of the Corps. I (We) further authorize any licensed physician to perform any procedure that he or she deems advisable in attempting to relieve
or treat any injuries or any related unhealthy condition in said participant that might be encountered during any necessary procedure or operation.
I (We) further consent to the administration of any anesthesia as deemed advisable by any licensed physician, and do hereby further authorize
any x-ray examination, medical or surgical diagnosis or treatment, and hospital care to be rendered to the participant under the general or
special supervision and on the advice of a licensed physician, surgeon, anesthesiologist, dentist or other qualified personnel acting under their
supervision.
In the event of an emergency where blood products are recommended, I (We) Do______ or Do Not______ give our authorization.
I (We), the undersigned, realize and appreciate that there is a possibility of complication and unforeseen consequences in any medical
treatment, and we assume any such risk on behalf of ourselves and the participant as stated herein. I (We) acknowledge that there has been
no warranty made as to the results of any such treatment or diagnostic procedure. Any medical or prescription costs not covered by insurance
are the sole responsibility of the undersigned. Any medical or prescription costs will be paid over the phone at the time(s) of service to the
provider. If this is not possible, all payments made by a Corps Representative will be billed to the member to be reimbursed to the Corps upon
receipt.
Each of the undersigned expressly acknowledges and agrees that they have read and understood the terms of this form. And they further
state that no oral representations, statements, or inducements apart from the foregoing written provisions have been made. All personal
information provided by undersigned in this form is said to be true to the best of their knowledge.
I (WE) HAVE READ, UNDERSTOOD, AND VOLUNTARILY SIGNED THIS RELEASE
_____________________________________
(Participant)
Date_______________________________
_____________________________________
Parent/Guardian Signature (if member under 18)
Date______________________________
*** This form is in effect from date signed through September 1, 2015 ***
Turn in all complete forms at a camp or send to Colleen Bledsoe at [email protected]
2015 Health History Form (page 1)
Member Information:
Name _______________________________________ Sex ________ Date of Birth ___________ Height _________
Weight ___________
All Allergies (Food/Medication/Etc.) _______________________________________________
_______________________________________________________________________________________________
Please answer all questions.
1.
YES
☐
NO
☐
2.
☐
☐
Do you have an ongoing or Chronic illness?
If so, please list:
3
☐
☐
Have you ever been hospitalized overnight?
If so, when and what for?
4.
☐
☐
Have you ever had surgery?
If so, when and what for?
5.
☐
☐
Are you currently taking or using any prescription, non-prescription (over-the-counter) medications,
vitamins, supplements or any medications used for weight loss or performance enhancement? If so,
please complete medication form.
6.
☐
☐
Do you have or use any medication used for emergencies such as a rescue inhaler or EpiPen®?
7.
☐
☐
Have you ever passed out during or after exercise?
8.
☐
☐
Have you ever been dizzy during or after exercise?
9.
☐
☐
Have you ever had chest pain during or after exercise?
10.
☐
☐
Do you get tired more quickly than your friends during exercise?
11.
☐
☐
Have you ever had racing of your heart or skipped heartbeats?
12.
☐
☐
Have you had high blood pressure or cholesterol?
13.
☐
☐
Have you ever been told you have a heart murmur?
14.
☐
☐
Have any family members or relatives died of heart problems or of sudden death before age 50?
15.
☐
☐
Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the
last month?
16.
☐
☐
Has a physician ever denied or restricted your participation in sports for ANY heart problem for any
reason such as anemia, blood clots, pulmonary issues, etc.?
17.
☐
☐
Do you have any current skin problems (for example, itching, rash, acne, warts, fungus, or
blisters)?
18.
☐
☐
Have you ever had a head injury or concussion?
Have you had a medical illness or injury since your last check up or sports physical?
If so, when and how many?
Turn in all complete forms at a camp or send to Colleen Bledsoe at [email protected]
2015 Health History Form (page 2)
YES
NO
19.
☐
☐
Have you ever been knocked out, become unconscious, or lost your memory?
20.
☐
☐
Have you ever had a seizure?
If so, when and when was your last seizure?
21.
☐
☐
Have you ever had a numbness or tingling in your arms, hands, or feet?
22.
☐
☐
Have you ever had a stinger, burner, or pinched nerve?
23.
☐
☐
Have you ever become ill from exercising in the heat?
24.
☐
☐
Do you cough, wheeze, or have trouble breathing during or after activity?
25.
☐
☐
Do you have asthma?
If so, please attach your asthma action plan
26.
☐
☐
Do you have seasonal allergies requiring medical treatment?
If so, please complete medication form
27.
☐
☐
Do you use any special protective devices (for example, a knee brace)?
28.
☐
☐
Have you had any problems with your eyes or vision?
29.
☐
☐
Do you wear glasses or contacts?
30.
☐
☐
Have you ever had a sprain, fracture, or dislocation of a muscle, tendon, bone or joint?
If yes, check appropriate box and explain
☐
☐
☐
☐
☐
☐
Head
Neck
Back
Chest
Shoulder
Upper Arm
☐
☐
☐
☐
☐
Elbow
Forearm
Wrist
Hand
Finger
☐
☐
☐
☐
☐
☐
Hip
Thigh
Knee
Shin/Calf
Ankle
Foot
Turn in all complete forms at a camp or send to Colleen Bledsoe at [email protected]